Abstract
This study aimed to identify the barriers that prevent currently practicing credentialed sonographers from using industry standard ergonomic scanning techniques. A quantitative descriptive design was used with data collected through an anonymous online survey of members of the Society of Diagnostic Medical Sonography. A total of 1234 members participated in the survey. The results confirmed previous reports that a high percentage (85.5%) of sonographers scan in pain, with the shoulder most commonly affected. Four barriers to ergonomic scanning practice were identified by more than 25% of the respondents, including being too busy, patient obesity, portable exams, and patients who are unable to cooperate. Some barriers are not within the control of the sonographer, such as patient obesity and patient condition, while other barriers are within moderate control, such as scheduling and lack of equipment. The focus should be placed on correcting and improving those barriers that can be controlled, thereby reducing the risk of work-related musculoskeletal injuries in sonographers.
Work-related musculoskeletal disorders (WRMSD) are aggravated or caused by workplace activities. According to the U.S. Department of Labor, Occupational Safety and Health Administration, 1 risk factors for WRMSD include (1) prolonged static positions, (2) awkward body postures, (3) forceful exertions, (4) repetitive movements, and (5) vibrations. With the exception of vibrations, sonographers routinely engage in all of the remaining risk factors.2,3 Of these, poor posture and repetitive movements have been reported as primary causes of WRMSD in sonographers,4–6 while other variables such as age, experience level, and exam types do not appear to affect WRMSD risk.4,5,7–9
Work-related musculoskeletal injuries are very common among sonographers. 3 The first report of WRMSD, known as sonographer’s shoulder, was introduced by Craig. 10 A decade later, Pike et al. 11 reported that 81% of sonographers scanned in pain, with 20% eventually having a career-ending injury. Again, 10 years later, another study reported the number of sonographers scanning in pain increased to 90%. 12 Both of these large-scale studies reported the shoulder and neck as the most common locations for pain.11,12 In response to these significant studies, there has been a proliferation of ergonomic education meant to reduce the prevalence of WRMSD in sonographers.
In 2011, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) required ergonomics be included in the curriculum of accredited sonography educational programs. 13 Significant literature is available to provide ergonomic best practices2,3 as is reporting on educational interventions, including informational workshops 7 and multimedia approaches. 4 While all these studies indicate the ergonomic information is well received by the sonographers and that participants plan to adjust their work habits following an intervention, assessment of long-term adherence to ergonomic scanning techniques had not been evaluated.
Moreover, despite the creation of industry standards, ergonomic best practices, and curricular requirements, there is still a reported lack of awareness and use of WRMSD prevention techniques among sonographers.4,7,12 There are a large number of sonographers who began their practice prior to the proliferation of ergonomic training; for example, over 50% of the sonographers who participated in the study by Fisher 4 had not received formal ergonomic training prior to the study. Moreover, even with ergonomic educational interventions, some sonographers find it difficult to execute or maintain proper techniques often due to increased workload.7,14
The rate of pain and injuries seems to persist, and many sonographers still continue to practice unsafe scanning techniques. There is a dearth of literature that addresses the reasons why sonographers do not practice or adhere to ergonomic scanning techniques. Insight as to why many sonographers routinely do not practice ergonomic scanning techniques may guide and improve future ergonomic educational interventions for currently practicing sonographers. Furthermore, understanding these factors may assist in enhancing curricular content requirements for sonography educational programs. Thus, the purpose of this study was to explore the barriers that prevent sonographers from practicing ergonomic scanning techniques.
Methods
This was a quantitative descriptive study using a survey method. Nonprobability, consecutive sampling was employed. The Society of Diagnostic Medical Sonography (SDMS) membership of approximately 27 000 active members 15 represented the accessible population. Eligible participants were SDMS members who were credentialed sonographers currently employed in a clinical setting. The study protocol was reviewed and approved by A.T. Still University Institutional Review Board.
Permission was granted by Carolyn Coffin and Joan Baker, cofounders of Sound Ergonomics, to adapt a survey used in a previous descriptive cross-sectional study to evaluate the presence and location of pain and diagnosis of work-related musculoskeletal injuries in sonographers. 12 The number of items from the original survey was reduced from 50 to 30 to promote completion. Primarily, items related to specific diagnoses and treatments of WRMSD were removed. Additional items were included to evaluate respondents’ knowledge and practice of industry standard ergonomic practices. Question choices included dichotomous responses (yes/no), multiple choice, multiple answer, open-ended free text, and Likert-type scale questions.
For organizational purposes, items were grouped into three sections: demographics, barriers in the work environment, and ergonomics knowledge and training. Included in the demographic section were items pertaining to personal and professional information, such as age, sex, race/ethnicity, credentials, primary areas of practice, employment, shift hours, experience pain while scanning, location of pain while scanning, years of scanning experience, number of scans per day, and average length of transducer time per exam. Variables evaluated as barriers to ergonomic practices in the work environment included being too busy, lack of awareness of ergonomic techniques, portable exams, and lack of ergonomic equipment. Respondents were also asked to report if there were no barriers present. An open-ended question was included for participants to offer other variables not included in the survey. Additional variables included whether participants attended a formal sonography education program that included ergonomics training and if proper ergonomic practice was reinforced during clinical training.
The SDMS successfully sent an invitation email containing a link to the online survey to 21 981 members who had opted in for emails regarding research. The first page of the survey included a recruitment letter, followed by a participation statement that served as consent for the study. Before gaining access to the survey, participants were asked to confirm they were credentialed and currently clinically employed. Individuals meeting both criteria were able to progress through the survey. If the criteria were not met, participants were rerouted to a thank you page and were unable to complete the survey. The survey was available for 45 days from September to mid-October, 2016. A single reminder email was sent to the members after 2 weeks.
Data were extracted from the survey platform, SurveyMonkey, and item-by-item analysis was conducted using IBM SPSS Statistics Version 24. Frequencies and valid percentages were calculated for the categorical variables. Shapiro-Wilk normality testing was performed (P < .05) for age, years of scanning experience, number of scans per day, and the average amount of transducer time per exam. The median, interquartile ranges (IQR), and minimum/maximum were reported for the non-normally distributed variables (i.e., Shapiro-Wilk results P < .05).
Results
Of the 21 981 participants invited, 1234 responses were collected. The inclusion criteria of currently credentialed in sonography and employed within a clinical setting were not met by 20 participants. An additional 156 participants did not sufficiently complete the survey. The total sample for analysis was 1058 responses, which represents a completion rate of 87.1%.
Results of all demographic data are reported in Table 1. The majority of participants were female (87.8%) and white (84.6%). Age ranged from 20 to 75 years, with a median age of 52 years (IQR = 16). The median number of years of scanning experience was 21 (IQR = 19). Registered diagnostic medical sonographer (RDMS) was the most frequently reported professional credential (81.9%), while registered musculoskeletal sonographer (RMSKS) was the least reported (7.4%). Obstetrics and gynecology (73.1%), abdomen (66.5%), and vascular (57.6%) were the highest reported specialty areas of practice. The majority of participants were employed full-time (76.3%) and worked eight-hour shifts (65.4%). The median number of exams per day was 10 (IQR = 4), and the median for minutes of scan time was 25 (IQR =10). The majority of the participants reported they scan in pain (85.5%). The shoulder (62.9%), hand/wrist (47%), and neck (44.1%) were the most common locations of pain experienced while scanning.
Participant Characteristics and Responses to Categorical Variables.
Note. The No. values represent the total number of responses for each individual question. RCS, registered cardiac sonographer; RDCS, registered diagnostic cardiac sonographer; RDMS, registered diagnostic medical sonographer; RMSKS, registered musculoskeletal sonographer; RT, radiologic technologist; RVS, registered vascular sonographer; RVT, registered vascular technologist.
Several barriers were identified that prevent currently practicing credentialed sonographers from using industry standard ergonomic scanning techniques to reduce their risk of work-related musculoskeletal disorders. In this sample, reports of being too busy (38%) and conducting portable exams (37.6%) were reported as nearly equal barriers that contributed to poor ergonomic practice. Two variables emerged from the open-ended free text data. Participants reported patient obesity (39.3%) and patients who are unable to cooperate due to limited mobility or critical conditions (26.8%) as additional barriers (see Figure 1).
The percentage of respondents who reported barriers to practicing ergonomic sonographic scanning techniques.
Although a less frequent barrier, the lack of ergonomic equipment was reported by a fairly large number of respondents (21.4%). Most participants reported having adjustable exam room tables (84.4%), scanning chairs (86.4%), and moveable keyboard on the ultrasound unit (88.3%). Despite the availability of adjustable equipment in more than three-fourths of all settings, the frequency of always making routine adjustments was much lower. The number of respondents who always routinely adjusted their equipment ranged from 29.9% to 45% (see Figure 2).
The percentage of sonographers within each category of frequency related to making adjustments to their types of sonographic accessory equipment.
Awareness of ergonomic techniques was the least frequently reported variable. In fact, despite the majority of respondents indicating that they did not attend a formal sonography program that included ergonomics in the curriculum (62.5%), there was a high level of awareness of the ergonomic best practices for scanning (86.8%). For respondents who received formal ergonomic training, only a small percentage (24.3%) indicated that proper ergonomic techniques were reinforced during their clinical training. Instead, emphasis was placed on the importance of learning to create and obtain diagnostic images rather than proper ergonomic posturing.
Discussion
This study demonstrated similar results to previous studies11,12 regarding the percentage of sonographers who scan in pain. While this study demonstrated a slight decrease in the percentage of sonographers who experience pain, over a span of 20 years since the landmark study by Pike et al., 11 the percentage has remained relatively stable. The shoulder was the most frequent location of pain, also consistent with previous studies.11,12 In contrast, pain in the hand and wrist surpassed the neck as the second location of pain as compared to the studies by Evans et al. 12 and Pike et al. 11 The agreement with previous studies provides external validity and suggests the likelihood of generalizability to sonographers beyond the members of the SDMS.
New information provided by this study relates to the barriers most frequently faced by sonographers in their attempt to incorporate ergonomics in the clinical setting. The findings of this study evaluated four barriers that prevent sonographers from using proper ergonomic scanning techniques, including being too busy, performing portable exams, lack of ergonomic equipment, and lack of awareness of ergonomic techniques. Being too busy could result in not having enough time between patients to rest muscles and/or manipulate and position sonographic equipment. Portable exams often do not allow for appropriate ergonomic set-up of the sonographic equipment, mainly due to size of patient rooms or existing patient care equipment located in the rooms. An increasing workload has been suggested as the reason behind the barrier of being too busy to make equipment adjustments or rest muscles in between patients. 14 The average number of exams noted in this study was similar to others,11,12 suggesting the average workload has not significantly increased over the years. Interestingly, the average length of scan time was also similar among all three studies.
The majority of participants in this study indicated they were aware of ergonomic best practices, which is in contrast to several studies that reported a lack of awareness of ergonomic scanning techniques as a significant reason sonographers are at risk for work-related musculoskeletal disorders.4,7,12 Most participants reported having access to ergonomic equipment in the exam room. This is in agreement with the recent study by Bagley et al. 16 However, the authors of that study only evaluated access to ergonomic equipment 16 rather than the frequency of making adjustments to the equipment, as included in this study. Having access to ergonomic equipment is the first step, but it is up to the sonographer to utilize the available ergonomic features. Participants in this study made adjustments to their available equipment more often than not.
In addition to these four previously reported barriers, this study identified two new barriers that are important to consider: patient obesity and patients who are unable to cooperate. Obese patients often require excessive pressure that can result in overexertion of the upper extremity. Patients who are unable to cooperate due to immobility typically require awkward postures from the sonographer to obtain necessary images.
Clinical Implications of Findings
The U.S. Department of Labor named sonography as one of the fastest growing professions, projecting a 46% growth increase by 2022. 17 Students considering and embarking on a future sonography career need to be aware of the possible harm they can do to themselves through incorrect scanning practices. 7 Currently practicing sonographers need to be willing to learn, practice, and adhere to good ergonomic practices 2 to reduce their risk of injury and improve career longevity. Gibbs and Edwards 5 investigated sonographers with experience levels of 15 to 35 years who were unaffected by WRMSD, illustrating the importance of ergonomic practices. The results indicated the participants were continually aware of potential problems, took time to adjust equipment, and took small breaks to allow muscles to relax and recover. 5 This study confirmed that adherence to ergonomic best practices for scanning is beneficial in the prevention of WRMSD.
In 2003, the Society of Diagnostic Medical Sonography developed industry standards for the prevention of WRMSD in sonographers. 18 Modeled on the standards, Baker and Coffin 2 suggested best practices related to the exam room that should be within the sonographers’ control. The primary adjustments that sonographers should implement are: (1) adjust height of exam table and chair to minimize exaggerated shoulder abduction and overreaching, (2) adjust the exam table and chair to alleviate trunk twisting and bending, and (3) position the ultrasound monitor directly in front of them to avoid neck flexion, extension, and twisting. Unfortunately, many of the most frequent barriers reported in this study suggest that reasons sonographers cannot practice ergonomic scanning techniques may be beyond their control, such as patient size and physical condition, which can remain obstacles despite making appropriate equipment adjustments. Many sonographers do not have influence over department budgets or scheduling services, which suggests another barrier, administrative support. Administrators need to be made aware of the financial implications of an injured sonographer versus the cost of an adjustable exam table and an appropriate scanning chair. Including both direct and indirect costs, approximately $771 500 is spent as a result of an injured sonographer, whereas the cost of creating an ergonomic work area is estimated to be $188 205. 19 The investment in an ergonomic work environment far outweighs the costs associated with an injured sonographer. Sonographers and employers need to work together to create a safer work environment and reduce occurrence of WRMSD and related costs due to these injuries. Additionally, institutional policies could be revisited to determine adequate scheduling of exams with consideration given to the duration of time needed to perform various studies and build in breaks to rest muscles in between exams. An internal review of the number of exams performed by each sonographer could be conducted and used to create a daily threshold to promote muscle recovery.
Limitations and Future Directions
The use of a nonvalidated survey instrument was a limitation in this study. Several items did not pertain to the research question or only provided supplemental information. Items were added to attempt to address the research question. As the study progressed, it was clear more specific items could have been included. In addition, the clarity of multiple survey items could have been improved. For example, many participants indicated having adjustable exam tables, chairs, and sonographic equipment, yet an identified barrier was lack of ergonomic equipment. This barrier is unclear whether it pertains to a specific piece of equipment or equipment in the sonographic exam room or patient rooms. When performing portable exams, patients’ beds may not be adequately adjustable, or appropriate scanning chairs may not be available. Finally, whether ergonomic scanning practices were included in the curriculum of a formal program was addressed but not to what degree (length of lecture vs. an entire course or embedded throughout the entire program).
A mixed method research design that included interviews might provide further insight to the perceptions of sonographers on the difficulties of ergonomic scanning and identify additional barriers not included in this study. Research to investigate relationships between the extent of ergonomic education, reinforcement of techniques, and adherence to techniques over time could provide information regarding risk reduction and occurrence of WRMSD. Recruiting students and/or recent graduates for this type of study could be beneficial for long-term assessment.
Additionally, such a study could address the social and behavioral attitudes toward the importance of ergonomic scanning. Finally, many of the best practices for ergonomic scanning pertain to the sonographic exam room. Research that includes collaboration with physical therapists and occupational therapists could be beneficial in creating a new set of ergonomic scanning techniques to use when forced to perform exams in a suboptimal setting (i.e., portable exams in patient rooms and exams performed on obese and/or immobile patients).
Conclusion
The purpose of this quantitative descriptive study was to explore the barriers that prevent sonographers from practicing ergonomic scanning techniques. Several barriers contribute to the difficulty of performing best practice ergonomic scanning techniques. Some are beyond the control of sonographers, while others are within moderate control. Focus should be on the barriers that can be changed to create a safer work environment. Despite the reported increase in the awareness of ergonomic scanning techniques and access to adjustable equipment, findings indicate that many sonographers continue to scan in pain. This suggests little improvement since the initial report of work-related musculoskeletal disorders in sonographers over 30 years ago. Sonographers need to become empowered to take care of themselves and recognize the importance of proper ergonomic posturing to reduce the risk and prevalence of work-related musculoskeletal injuries.
Footnotes
Acknowledgements
The authors would like to thank Sound Ergonomics for the permission to adapt and use their survey and the Society of Diagnostic Medical Sonography for distribution of the survey to its members.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.